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Difficulty: MediumHematology and Oncology

A 72-year-old man with a history of IgG kappa multiple myeloma, chronic obstructive pulmonary disease (COPD), and heart failure with preserved ejection fraction is admitted for symptomatic anemia. His hemoglobin is 6.8 g/dL, and a transfusion of packed red blood cells is initiated. Two hours later, he develops acute-onset respiratory distress. The transfusion is immediately stopped.

Vital signs are temperature 37.1°C (98.8°F), blood pressure 175/95 mm Hg, pulse 115/min, and respirations 28/min. Pulse oximetry is 85% on room air. Physical examination shows an anxious patient in moderate respiratory distress with prominent jugular venous distension. Chest auscultation reveals bilateral basilar crackles, diffuse end-expiratory wheezing, and a third heart sound (S3).

Laboratory studies from admission show:

TestResultReference Range
Thyroid-stimulating hormone (TSH)0.2 µU/mL0.4-4.0 µU/mL
Free T40.7 ng/dL0.9-1.7 ng/dL

A urine culture obtained at admission for routine screening grew >100,000 CFU/mL of *Escherichia coli* that is sensitive to all tested antibiotics, including amoxicillin and cephalexin. The patient denies dysuria.

The patient's daughter, who holds a valid healthcare proxy and previously confirmed the patient's wish for full medical interventions, is en route to the hospital. The patient's estranged son is currently at the bedside and demands that the team withhold all respiratory and fluid management to transition the patient immediately to comfort care.

Which of the following is the most appropriate next step in the management of this patient's acute respiratory distress?

  1. Administration of intravenous furosemideAnswer
  2. B
    Administration of nebulized albuterol and intravenous methylprednisolone
  3. C
    Initiation of intravenous piperacillin-tazobactam
  4. D
    Administration of intravenous levothyroxine
  5. E
    Withholding acute medical interventions as directed by the son

Answer

Administration of intravenous furosemide
The correct answer is the administration of intravenous furosemide. This patient is experiencing transfusion-associated circulatory overload (TACO), a form of acute cardiogenic pulmonary edema caused by rapid volume expansion from the transfused blood product. Risk factors include advanced age and underlying cardiac disease, such as his heart failure with preserved ejection fraction. The clinical presentation is characterized by respiratory distress, hypertension, tachycardia, hypoxia, jugular venous distension, pulmonary crackles, and an S3 gallop. The presence of wheezing ('cardiac asthma') can also occur secondary to peribronchial edema. Immediate management involves stopping the transfusion, providing supplemental oxygen, and administering intravenous loop diuretics (such as furosemide) to reduce the acute volume overload.

Step-by-Step Solution

1
Analyze the clinical presentation and temporal relationship.
The patient developed acute respiratory distress, hypertension, jugular venous distension, crackles, and an S3 gallop shortly after starting a blood transfusion.
To identify the acute complication as Transfusion-Associated Circulatory Overload (TACO).
2
Differentiate from competing diagnoses.
While wheezing is present (suggesting a COPD exacerbation) and lung infiltrates occur in TRALI, the combination of hypertension, JVD, and an S3 specifically points to cardiogenic pulmonary edema.
To avoid the common trap of misdiagnosing TACO as a primary pulmonary exacerbation or TRALI.
3
Determine the appropriate management.
After stopping the transfusion and providing supplemental oxygen, the next step is to administer intravenous loop diuretics.
To acutely reduce intravascular volume and alleviate cardiogenic pulmonary edema.

Key Concept

Diagnosis and management of Transfusion-Associated Circulatory Overload (TACO)
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Topics

Hematology and Oncology

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